Exercise in Swallowing Therapy (Part 2 of a 3-Part Series)

In the first installment of “Exercise in Swallowing Therapy” the roles of overload and adequate
duration of therapy were discussed. In this second installment, additional exercise principles of intensity progression and repetition are described.

1. In order to make continued gains, the exercise load must be systematically and
progressively increased.

“To maximize gains over time, the absolute value of load placed on the muscle must be progressively adjusted over the course of the exercise program. This practice, known as progressive resistance, is necessary to maintain the relative physiologic load as a proportion
of the maximal force-generating capacity.” ¹

Systematic progressive strengthening with intense practice yields superior outcomes.²

Our colleagues in PT do not randomly select a weight when providing resistance exercise. Instead, weight is systematically progressed based on the patient’s ability to correctly perform exercise beyond the target number of repetitions within an appropriate intensity range. Similarly, level of resistance and quality of performance should be considered when progressing swallow exercise. Therefore, simply having a patient consume a meal as a therapeutic intervention offers nothing in the way of systematic progression.

2. Repetitions matter

“In addition to exposing the muscle to adequate amounts of load during strength-training efforts, the manner in which these efforts are structured can also impact outcomes. The volume of exercise can be manipulated by adjusting the number of repetitions performed in sequence, total sets completed, the length of rest periods between sets, the number of days of exercise per week, and the number of weeks the exercise is performed.” ¹

In light of the number of times we swallow per day (up to 2000), if the patient is performing 2,000 dysphagic swallows per day, you may be wondering how performing ten effortful swallows could affect any change. While the research body of evidence to support strengthening exercise for swallowing is inconclusive with respect to the best repetition dose to optimize outcomes, there are a few studies that shed some light on the topic:

• McCullough taught us that 30 to 40 Mendelsohn’s are required for 20 days to have a
  rehabilitative effect.³
• Athukorala incorporated 100 swallows into her sEMG based swallow program.⁴
• Shakers, EMST, and IOPI have only been studied with one specific dosage. The ideal intensity
  remains unknown.
• Repetition allows novel behaviors to become learned, automatic actions.⁵

The final segment of “Exercise in Swallowing Therapy” will provide one additional principle and then examine commonly used interventions to determine how they line up against the principles of exercise.

Reference:
1. Burkhead L M, Sapienza C M, & Rosenbek J C (2007). Strength-training exercise in dysphagia rehabilitation: principles, procedures, and directions for future research. Dysphagia, 22(3), 251-265.
2. Carnaby-Mann GD, Crary MA. (2010). McNeil dysphagia therapy program: a case-control study. ArchPhys Med Rehabil, 91(5), 743-749.
3. McCullough G H, Kamarunas E, Mann G C, Schmidley J W, Robbins J A, & Crary M A (2012). Effects of Mendelsohn maneuver on measures of swallowing duration post stroke. Top Stroke Rehabil, 19(3), 234-243.
4. Athukorala R, Jones R, Sella O, Huckabee M (2014) Skill training for swallowing rehabilitation in patients with Parkinson’s disease.
Arch Phys Med Rehabil. 95(7):1374-82.
5. Kleim JA & Jones TA (2008). Principles of Experience-Dependent Neural Plasticity: Implications for Rehabilitation After Brain damage. J Speech Lang Hear Res, 51(1), S225-S239.